Intercity Lines Payment Authorization Form


Please fill out the fields & sign below if paying with a credit card. 

Name on Credit Card:    

Date: 

Phone Number:   

Email:   

Year, Make, & Model of the Vehicle being Transported:   

Pick Up City:   

Pick Up State:

Delivery City:   

Delivery State:  

Cost of Transport:   

Billing Street Address:   

Billing City, State, & Zip Code:

For your security, we will call you for your credit card #. We typically run Credit Card payment’s once pick up has been scheduled 2-3 days before. Credit Card Payments can be made using a Visa or MasterCard. We do not accept American Express or other cards. We do not accept payment from 3rd parties. 

I, the cardholder, authorize Intercity Lines, Inc to charge my Visa or Mastercard for payment of the vehicle transport described above. (PLEASE DO NOT PUT ANY PUNCTUATIONS IN YOUR LEGAL NAME. IT WILL NOT ALLOW YOU TO SIGN)

Leave this empty:

Signature arrow


Signature Certificate
Document name: Intercity Lines Payment Authorization Form
lock iconUnique Document ID: ca15b5862795d68b80412262ababba1d539639e6
Timestamp Audit
October 26, 2018 11:28 am EDTIntercity Lines Payment Authorization Form Uploaded by NoReply IntercityLines - angela@intercitylines.com IP 73.89.228.234, 127.0.0.1, 184.168.224.71, 0.0.0.0
March 22, 2019 11:40 am EDTICL inc - dean@Intercitylines.com added by Intercity Lines - dean@intercitylines.com as a CC'd Recipient Ip: 50.250.58.137
March 22, 2019 12:59 pm EDTICL inc - dean@Intercitylines.com added by Intercity Lines - deanwilson@intercitylines.com as a CC'd Recipient Ip: 50.250.58.137
March 22, 2019 1:11 pm EDTsharon S - sharon@intercitylines.com added by No Reply Intercity Lines - dean@intercitylines.com as a CC'd Recipient Ip: 50.250.58.137
March 22, 2019 1:11 pm EDTdean w - dean@intercitylines.com added by No Reply Intercity Lines - dean@intercitylines.com as a CC'd Recipient Ip: 50.250.58.137
March 22, 2019 1:14 pm EDTsharon S - sharon@intercitylines.com added by No Reply Intercity Lines - deanwilson012@gmail.com as a CC'd Recipient Ip: 50.250.58.137
March 22, 2019 1:14 pm EDTdean w - dean@intercitylines.com added by No Reply Intercity Lines - deanwilson012@gmail.com as a CC'd Recipient Ip: 50.250.58.137
August 12, 2019 2:51 pm EDTsharon intercity - sharon@intercitylines.com added by NoReply IntercityLines - deanwilson@intercitylines.com as a CC'd Recipient Ip: 50.250.58.137, 185.93.229.11
August 22, 2019 9:46 am EDTsharon intercity - sharon@intercitylines.com added by NoReply IntercityLines - deanwilson@intercitylines.com as a CC'd Recipient Ip: 50.250.58.137, 185.93.229.11